Background

Abnormal pap smears are relatively common and may be present in up to 5-10% of the population being screened. The report of an abnormal pap creates moderate anxiety for a woman because of the implication that it may represent cancer. In most cases however it does not represent cancer but rather irritations and pre-malignant changes that may need diagnostic workup and therapy to prevent cancer of the cervix.

Goals

The pap smear is a screening test and as such, it does not represent the gold standard of diagnosis. If the pap smear is abnormal, a biopsy is usually performed and that is the basis on which any treatment is prescribed. Pap smears may be reported as a worse grade than the actual cervical lesion or may be not as bad as the actual lesion.

It is also important to remember that pap smears may have as much as a 20-25% false negative rate; thus they can miss lesions. For that reason, a series of annual pap smears are recommended to decrease the likelihood that a false negative report is issued giving false reassurance that everything is normal.

Colposcopy is routinely used for management of abnormal pap smears because it indicates where to perform a biopsy that will yield the most abnormal changes on the cervix. Thus the biopsy that is obtained which is colposcopically directed is less likely to err in the direction of underestimating potential malignant change.

Cervical lesions

Background - importance and magnitude of problem

Diagnostic goals - for overall category

Anomalies

Developmental

Prenatal steroid exposure/DES related

Polypoid lesions

Endocervical polyps

Endometrial polyps

Prolapsed submucous fibroid

Papilloma virus

Inflammations, ulcerations and masses

Eversion/ectropion

Trauma

Herpes

Syphilis

Squamous cell carcinoma of cervix

Adenocarcinoma of cervix

Adenosquamous carcinoma of cervix

Cervical pregnancy

Old lacerations

Nabothian cysts

Background

The cervix may often undergo trauma from both pregnancy, labor and delivery, and that associated with sexual relations. Lesions are not uncommon, however, most of them are benign.

Goals

Many cervical lesions are recognizable by an experienced observer and do not need further studies eg., Nabothian cysts, cervical lacerations, eversion, or condyloma acuminatum. Any lesion that is not readily identifiable, should be biopsied to make sure that there is not a malignant process present. Any visible polyps are removed even though they are rarely malignant. If polyps remain in place they will usually become ulcerated and eventually cause abnormal uterine bleeding.

Cervical discharge

Background - importance and magnitude of problem

Diagnostic goals - for overall category

Gonorrhea

Chlamydia

Non-Specific Cervicitis

Background

Mucous is normally present in the cervix and is produced by endocervical glands. It is clear in color or an opaque grayish white. Cervical discharge is usually an observation of the examining physician rather than a patient complaint. On occasion, patients may complain of excessive vaginal discharge and the source of that is actually from the cervix.

Goals

Any cervical mucous that is yellowish in color, or not clear or opaque white, should have cultures taken. It may represent infection with sexually transmitted diseases.

Vaginal discharge and pruritus

Background - importance and magnitude of problem

Diagnostic goals - for overall category

Physiologic discharge

Non-specific bacterial vaginitis

Trichomonas vaginitis

Candida yeast vaginitis

Atrophic vaginitis

Foreign body vaginitis

Prepubertal gonococcal vaginitis

Allergic reaction

Rectovaginal fistula

Background

Most women at some time in their lives will have one or more episodes of vaginal discharge with itching, or burning on the vulva. Vaginal infections are quite common and many over the counter remedies exist.

Goals

Most problems in this category should be specifically diagnosed in order to prescribe the most effective therapy. Most commonly diagnosis is performed by direct microscopic examination of the discharge suspended in saline. Occasionally cultures and other studies need to be performed. Chronic recurrent episodes of vaginal discharge are a much more difficult diagnostic category. Attention must be turned toward what is the cause of disruption of the normal vaginal flora which keeps vaginal infections from developing rather than what is the current infectious agent.